Experience with Ulcerated, Bleeding Autologous Dialysis Fistulas

Abstract

The ulcerated autologous dialysis fistula is a life-threatening lesion and requires prompt surgical intervention to reduce mortality. The frequency of this problem appears to be increasing. Simple suturing of the ulcers was not consistently effective in remedying the problem and should be utilized as a temporizing measure until surgical correction can be undertaken. Fistulas can be uniformly salvaged with surgical intervention enabling uninterrupted dialysis treatments.

Limberg Skin Flap for Treatment of Necrosis and Bleeding at Haemodialysis Arteriovenous Angioaccess Puncture Sites

“…Moreover, a regional investigation conducted by Ellingson et al 3 suggested that these national figures were potentially underestimated owing to major under-reporting of fatal haemorrhages. Finally, of 24 patients with ulcerated lesions retrospectively identified by Jaffers and Fasola, 4 two patients died from a major haemorrhagic event before surgical consultation.…”

“…If the necrosis area is limited, minimal skin mobilisation and suturing or advancement flap have been reported to be successful after ulcer excision and vessel wall suturing. 4 For larger ulcerated areas, a locally rotated fullthickness skin flap might be the best option. In 1946, Limberg described a standardised locally rotated flap with 60 and 120 angles for primary closure of rhomboid defects after excision of skin lesions.…”

“…Two recent series 2,3 reported a total of 188 deaths by exsanguination. However, there is only one recent report 4 of the various therapeutic options to be used in such cases, from access ligation to conservative surgical treatment with elliptical excision of the ulcer and vessel repair associated either with direct skin suture or with skin advancement flap. We therefore reviewed our series of end-stage renal disease (ESRD) patients who, in the absence of clinical infection, were treated by performing a locally rotated Limberg skin flap for angioaccess ulceration and bleeding, frequently combined with percutaneous transluminal angioplasty (PTA) for downstream stenosis.…”

Resection of puncture site necrosis over an arteriovenous fistula: Endoclamp use for preservation of cannulation sites

“…The appropriate-sized balloon catheter is selected by perioperative ultrasound measurements and proximal and/or distal vascular control are achieved by endo-occlusion (Figure 4 The topic of SN overlying an AVF cannulation site has been generally reviewed with reports focusing on vascular access aneurysms and bleeding. [1][2][3][4][5][6] Area (or cluster) cannulation is frequently implicated as a major factor in formation of these lesions and should be avoided. 7 Other related factors may include elevated AVF pressure due to high flow or outflow vein stenosis and are commonly associated with these lesions.…”

“…Skin necrosis (SN) overlying an arteriovenous fistula (AVF) at a site of repetitive cannulation ( Figure 1) is a relatively common and potentially life-threatening situation that may complicate an AVF. [1][2][3][4][5][6] It presents an urgent dilemma for the vascular access surgeon with the risk of exsanguination in addition to a desire for maintaining a functional AVF after repair. Limited AVF length is a common problem and may render cannulation sites unusable when surgical proximal and/or distal control are established.…”